The causes of high pulse should be better known
and, consequently, better managed. The case of President McKinley gives emphasis
to this. We have no disposition to criticise that case or its management. An
abdominal wound of that nature, in our hospital service in the Civil war [sic],
we regarded as necessarily fatal and, usually, such cases lived but a short
time. A ball could not plunge through the stomach so near the median line without
injuring the cæliac plexus, or the great abdominal brain as it has been termed.
The absence of nausea and vomiting showed that the vagus was not injured, to
that degree. But there was inaction of the inhibitors so that the heart went
off at a gallop and continued at a very high rate until the hour of collapse
on that fateful Friday. The attending family physician explained to the alarmed
nation that a high pulse rate was habitual with the President. That may have
been true, and that leads us to inquire more earnestly as to the cause of a
high pulse rate, consequently, the very best management.
We saw today, and have seen, in the clinic of
this college and at Cook County Hospital many cases of tachycardia dependent
upon many diseased conditions. To understand these cases the fundamental facts
of cardiac anatomy and physiology were emphasized before the pathology and therapeutics
can be comprehended and applied intelligently.
The heart, like any other muscle, has one function
and that is contraction, to be followed by relaxation. Its twin ventricles work
together, usually in a peculiar way. As the different layers of muscles indicate,
they elongate and rotate the heart slightly; they work and rest. To control
this action we have the nerves and blood supply. If the blood is deficient,
this pump, like any other, works rapidly as in the last case before us. The
nerves are to control, retard or accelerate it. They are the governors of this
engine. All drugs that quiet the action of the inhibitors allow the accelerators
to hurry the heart. Any obstruction acts as a stimulus to increase the cardiac
action and force; so we come to differentiate:
1—Rapid anæmic heart;
2—Stimulated pulse; and
3—Obstructed forceful pulse.
1—The anæmic pulse is small and compressible
and easily recognized. We meet it in long lasting disease and in impoverished
bodies. The principal remedies that occur to us are Arsenicum, [375][376]China, Phosphorus, Sulphur, etc., drugs with a long-lasting
tachycardia and systemic waste and weakness.

2—A stimulated pulse is always an abnormal one.
We look for a mental, nervous, systemic or accidental cause. Stimulants, so
called, all produce rapid heart action, usually as a secondary effect. Alcohol,
tobacco, tea, coffee are the domestic agents that produce a very lasting tachycardia.
Nervousness usually produces paroxysmal tachycardia. Mental emotion or activity
tend to produce a longer lasting tachycardia. A small heart, as we have seen
in the clinic, gives us a rapid pulse. A small person has, as a rule, a more
rapid heart than a tall one. The child has a rapid heart, because the circuit
is short; and in the aged it tends to rapidity because the obstructed capillaries
also shorten the systemic circuit. This very obstruction causes a rapid heart
and hypertrophy jaripassu, especially in the fleshy, as was the
President. The heart, normally, begins to enlarge between the ages of 50 to
60 years. Many of the cases of rapid, stimulated heart we meet in men are due
to the action of tobacco; so we should always ascertain the cause and attempt
to antidote the bad effects.

3—We must interrogate every organ to see if
there is anywhere obstruction from habit or disease. This form of tachycardia
we have seen in goitre, in gastritis, hepatitis, constipation, nephritis; and
tachycardia is often a symptom of cerebral lesion. A persistent rapid pulse
is also a serious symptom of disease of the chest, lungs or, sometimes, of the
heart itself. It is a pathognomonic symptom of tuberculosis when the other symptoms
are also present. It is a constant symptom of fever. So a rapid pulse must always
find a proper explanation. A traumatic pulse may be first slow in shock but
then becomes rapid, most rapid.
One of the first remedies given in shock usually
is Alcohol in some form. This is a remedy that acts very similar, hastening
the reaction of a rapid pulse. Big doses or moderate doses of alcohol long continued
tend to weaken the heart by dilation. The action of tobacco is well known by
all who have attempted to acquire the habit. No one can forget the nausea and
faintness of its primary action. The slow pulse tells of cardiac inhibition.
Those who have attempted to break off the habit will also remember the reproduction
of the primary cardiac weakness. So great is it that few can break off the habit
without help through this “slough of despond.” The desire of the old seductive
stimulant becomes [s]o great that few can resist, and hence they return to its
use. The speaker fought this physical depression of its primary action for weeks.
Every whiff of a cigar or pipe prolonged the agony for months until a remedial
antidote was found. Now there is a physical repugnance to tobacco. These antidotes
every physician should know, and especially every surgeon. President McKinley
should have been allowed his tobacco, or given an antidote. Most surgeons know
that alcoholics stand operations badly, and this stimulant is often continued,
and that wisely, unless the surgeon calls into play the powerful antidotal action
of Arsenicum or Nux Vomica.
Hahnemann studied the effects of common remedies
used in his day, and so must we. Tobacco is used so extensively and so freely
that every physician should recognize its constitutional effects as readily
as he can the round red fissured tobacco tongue we see so often in the clinic.
There are several antidotes to tobacco. [376][377]Arsenicum antidotes chewing tobacco. Nux antidotes some of the
stomach symptoms, while Phosphorus controls the palpitation of tobacco.
For the tobacco heart Allen says Phosphorus is the antidote. Plantago
Major has several times caused an aversion to tobacco.
One summer the writer was treating a man for sour
stomach and diarrhrea [sic], and the indicated similar remedy was Pulsatilla.
A few days after, he returned and wanted to know what I had given him. I asked
why, and he replied, “Why, it has taken away all my appetite for my tobacco;
it don’t taste right now; I don’t want it.”
To understand the kind of palpitation that Phos.
cures we read:
“Pulse accelerated, full and hard.”
“Pulse sometimes double.”
“Pulse small, weak and frequent.”
This, doubtless, was the kind of pulse President
McKinley had.Phosphorus also has “dilation of the heart
from fatty degeneration.” That again corresponded to the reported condition
of the dead President’s heart.Digitalis also causes rapid heart, but
it does not antidote tobacco. Woodward says that Tabacum affects the
sensory organs first, then the circulatory, spinal, digestive and the genito-urinary
system. While Digitalis is not similar, it affects, first, the sensory
organs, then the circulatory, next the digestive, then the genito-urinary and
after that the spinal centers. Not following the same course through the organs
they cannot be antidotes, strictly speaking. They differ also in the emphasis
made upon the organs. Digitalis produces greater tension upon the arterial
system, and, if relief is not afforded by way of the kidneys, venous stasis
results giving its characteristic slow, intermittent pulse and blue extremities.
Tabacum has a soporific or soothing effect upon the nervous system, causing
mental languor. They therefore differ in their method of relief. According to
Woodward’s grouping of sequences, alcohol stands nearest to Tabacum in
the order of effects among the organs. Then comes Cannabis, Cocaine
and Amyl nitr.
When I read that the attending staff of surgeons
were giving Digitalis to bring down the pulse of President McKinley I
was surprised and pained at this old and mistaken use of this powerful drug.
I was sorry to see that some of our best surgeons were not up on modern therapeutic
methods. Now the better informed give not Digitalis to “bring down the
pulse,” but when slow and intermitting from venous stasis, then they give it
to “bring up the pulse.” This proper [u]se of Digitalis should be proclaimed
far and near, so that no surgeon will hereafter lessen the vitality of his patient
by a wrong use of Digitalis. A rapid pulse tells of some grave or dangerous
condition and this, certainly, should not be augmented by the wrong use of powerful
drugs.